Provider Demographics
NPI:1881945475
Name:LIGHTHOUSE PEDIATRIC & AFTER HOURS CLINIC, PA
Entity type:Organization
Organization Name:LIGHTHOUSE PEDIATRIC & AFTER HOURS CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:LASHELLE
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-488-4171
Mailing Address - Street 1:501 SPRINGRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5633
Mailing Address - Country:US
Mailing Address - Phone:601-488-4171
Mailing Address - Fax:601-488-4175
Practice Address - Street 1:501 SPRINGRIDGE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5633
Practice Address - Country:US
Practice Address - Phone:601-488-4171
Practice Address - Fax:601-488-4175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16949208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04583552Medicaid